SEAT OF PRIMARY INVASION. 223 



primary union, and the cavity in the mouth closed slowly by granula- 

 tion. The patient's general health improved rapidly until six weeks 

 after the operation, when the neck below the scar became swollen, 

 followed in a short time by the formation of abscesses reaching from 

 the angle of the jaw to the clavicle, and posteriorly as far as the spine 

 of the scapula. Numerous openings were made and efficient drain- 

 age established, but suppuration continued and the patient became 

 extremely emaciated. The suppurative process extended, and four 

 months after the first operation the patient died, the symptoms during 

 the last days of life pointing to a hypostatic pneumonia. Actinomyces 

 were constantly found in the pus during the entire course of the disease. 

 I believe that the recurrence of the disease after operation was due to 

 an imperfect removal of infected tissues in the posterior and lower 

 portion of the pharynx. 



CASE II. This case came under my care during the summer of 

 1887. Patient was a young man who was employed on a farm. About 

 five months before he was admitted into the Milwaukee Hospital he 

 had a number of teeth extracted from the right upper jaw under the 

 belief that the teeth, some of which were decayed, were the cause of 

 the pain and swelling in that region. The physician in attendance 

 diagnosticated sarcoma of the upper jaw, and sent the case to me for 

 operation. On my first examination 1 found a swelling involving the 

 right side of the face, extending from the zygomatic arch to near the 

 lower border of the lower jaw, involving the deep tissues and being 

 connected with the alveolar processes of the posterior portion of the 

 upper jaw. The swelling was firm, and without well-defined margins. 

 No evidences of suppuration. The history of the case, and particularly 

 the location, extent, and physical properties of the swelling, led me to 

 the opinion that it was the result of actinomycotic infection. All 

 infected tissue was thoroughly excised through a large external inci- 

 sion, the jaw-bone scraped and cauterized. The entire thickness of the 

 cheek, with the exception of the skin and superficial fascia, appeared 

 to be transformed into granulation tissue. In the granulations numer- 

 ous yellow seed-like bodies were found, which under the microscope 

 showed the typical structure of the ray-fungus. The mycelia were 

 not as bulbous as we find them pictured in the books, but the distal 

 extremity appeared to be surrounded by dust-like bodies presenting 

 the appearance of a small brush. Some of the mycelia appeared to be 

 more covered than others. These minute bodies I looked upon as 

 spores. In the first case in which suppuration had taken place I never 

 succeeded in finding the actinomyces perfect and complete ; in the 

 second case suppuration had not taken place, and the fungus always was 

 found in a perfect state and in a condition of spore-production. These 

 cases present a striking contrast both in regard to the local conditions 

 and the ultimate termination. In the first case a secondary infection 

 had already taken place, and the phlegmonous inflammation induced 

 by the pus-microbes prepared the tissues again for the diffusion of the 

 actinomycotic process ; while in the second case the process had not 



